Registered Nurse-Transitional Case Management

About the role

Location: IU Health Arnett. Position Summary: IU Arnett Hospital is seeking a dedicated and experienced Registered Nurse - Transitional Case Management to join our team. In this pivotal role, you will coordinate care for high-risk patients post-discharge, with a focus on reducing readmissions and ensuring seamless transitions across care settings. This position offers an excellent opportunity to make a meaningful impact on patient outcomes through comprehensive discharge planning, patient education, and collaborative care management.

Responsibilities

• Collaborate with multidisciplinary teams to develop and implement individualized care plans for patients from pre-admission through post-discharge.
• Identify high-risk patients and implement targeted interventions to prevent readmission, ensuring smooth transitions of care.
• Conduct thorough phone triage to assess patient needs, provide education, and coordinate necessary services.
• Demonstrate strong problem-solving skills by identifying barriers, collaborating on solutions, offering alternatives, and following up to ensure resolution.
• Utilize positive reinforcement techniques by recognizing patient achievements, encouraging progress, and providing specific praise to foster engagement.
• Ensure patients are appropriately assigned to the correct level of care and receive necessary services, including post-discharge support and follow-up.
• Perform accurate, timely discharge planning and documentation, facilitating effective communication with patients, families, and healthcare team members.
• Demonstrate accountability and follow-through by providing timely reminders, ensuring the delivery of necessary materials, and maintaining ongoing patient engagement.
• Work with third-party payers to secure coverage and approvals, ensuring financial clearance for services.
• Administer patient education and prevention programs to promote health and wellness.
• Monitor, evaluate, and modify care plans as necessary to optimize patient outcomes.
• Maintain compliance with medical record documentation, healthcare regulations, and organizational policies.

Qualifications

• Requires an Associates of Nursing (ASN).
• Bachelors of Nursing (BSN) preferred.
• Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license.
• Requires that the RN has graduated from a nationally accredited nursing program.
• Minimum of 3-5 years of relevant experience, preferably in ambulatory care, home health, or care management.
• Phone triage experience is preferred.
• Requires Basic Life Support certification through the AHA.
• Other advanced life support certifications may be required per unit/department specialty according to patient care policies.
• Requires proficiency in Microsoft Office and applications.
• Requires understanding of medical record requirements, regulations and policies.

Skills and Competencies

• Excellent communication, organizational, and critical-thinking skills.
• Proven problem-solving skills, including the ability to:
  • Identify barriers
  • Collaborate on solutions
  • Offer alternatives
  • Follow up effectively
• Ability to utilize positive reinforcement strategies:
  • Recognize achievements
  • Encourage progress
  • Provide specific praise
• Demonstrated accountability and follow-through:
  • Provide reminders
  • Ensure materials are delivered
  • Maintain ongoing engagement with patients

Schedule

Monday – Friday, Day Shift, Hybrid Remote (25-50% in office requirement)